Guidance

3 Considerations

3 Considerations

The PDG took account of a number of factors and issues in making the recommendations.

Service provision

3.1 The PDG acknowledged that everyone should have equal access to services and support. Interventions aimed at improving the health of those living in the poorest circumstances and with the poorest health can only help a relatively small part of the population. They may not be enough to bring these groups closer to the population average – nor to reduce wider social and health inequalities. (Graham and Kelly 2004). Large numbers of people who are not categorised as 'vulnerable' may be relatively disadvantaged in health terms. These disadvantages usually increase, the further people are from the top of the social scale, so policies and interventions to tackle health inequalities need to extend beyond those with the poorest health.

3.2 It is important that universal services (for example, home visiting by health visitors and midwives) are available for all families with infants and young children. A universal service does not imply that every family has the same needs. Some are likely to need more support than others (for example, if the mother or child has a physical or learning disability). Health visitors should be proactive and visit all mothers, parents and carers of infants and pre‑school children at home (where possible) to assess their needs. Those with identified needs should receive intensive support (Blair and Hall 2006). The Health in Pregnancy Grant should increase opportunities for contact with a health professional as early as possible in pregnancy so that the support required can be individually assessed.

3.3 For each recommendation, a list of 'who should take action' is provided. However, responsibility for implementation often goes beyond those listed, especially where it involves a 'whole systems' or team approach operating within and across the NHS and local authorities (for example, when services are provided by children's centres, children's services or as part of a local area agreement).

Evidence

3.4 The guidance draws on a range of data: scientific, systematically derived evidence of effectiveness; context‑sensitive evidence on the economic costs and benefits; and evidence from practice including professional opinion and expert judgement (Lomas et al. 2005). The PDG recognised that there is a shortage of controlled studies in a number of key areas. For example, there is a lack of population or intervention studies on how to improve the nutritional status and dietary intake of young children, pregnant and breastfeeding women, and to improve dental health especially among younger children. Much of the existing published work was not carried out in the UK and this needs to be taken into account when considering its relevance. Where there was little evidence from controlled studies, the PDG considered observational data from UK cohorts and national surveys, coupled with evidence from practice. This was considered a valid and appropriate basis for the recommendations.

3.5 Overall, the evidence suggests that dietary interventions which recognise the specific circumstances facing low‑income families, teenage parents and mothers from minority ethnic or disadvantaged groups are likely to be more effective than generic interventions. The evidence often lacked contextual detail and measures of effectiveness were not clearly linked to different socioeconomic, ethnic or vulnerable groups. This made it difficult for the PDG to target recommendations at particular groups. However, it was clear that services need to be accessible and applicable to everyone, including those with learning, physical or other disabilities. The PDG also emphasised the importance of monitoring and evaluating new interventions to broaden the evidence base.

Maternal diet

3.6 Up to 50% of pregnancies are likely to be unplanned, so all women of childbearing age need to be aware of the importance of a healthy diet. Nutritional interventions for women who are – or who plan to become – pregnant are likely to have the greatest effect if delivered before conception and during the first 12 weeks.

3.7 A healthy diet is important for both the baby and mother throughout pregnancy and after the birth. However, 39% of people from low income groups report that they worry about having enough food to eat before they receive money to buy more. Similarly, about a third (36%) report that they cannot afford to eat balanced meals. Overall, one fifth of adults in low income groups report reducing the size of – or skipping – meals. Five per cent report that, on occasion, they have not eaten for a whole day because they did not have enough money to buy food (Food Standards Agency 2007).

3.8 Women who are overweight or obese before they conceive have an increased risk of complications during pregnancy and birth. This poses health risks for both mother and baby in the longer term (Morin 1998). There is also evidence that maternal obesity is related to health inequalities, particularly socioeconomic deprivation, inequalities within ethnic groups and poor access to maternity services (Heslehurst et al 2007).

3.9 One of the biggest challenges when trying to improve the diets of women, children and families is how to help them change their behaviour (rather than just their knowledge and attitudes). The PDG emphasised that a multidisciplinary approach (involving and supporting the families themselves and the wider community) is the most effective option. It is important that the team involved adopts a non‑judgemental, informal and individual approach based on advice about food (rather than just nutrients).

3.10 The PDG welcomed the introduction of Healthy Start vouchers to buy fruit and vegetables (as well as milk and infant formula). These are available to pregnant women and families with a child aged under 4 years. Those eligible include people on income support and income‑based jobseekers allowance and those with an income of £14,495 a year or less. All pregnant women under 18 also qualify, whether or not they are on benefits.

3.11 The Group felt, however, that the vouchers were likely to have a greater impact if their monetary value was increased, and if they could be used in food cooperatives and other community‑based food initiatives. Community‑based initiatives may offer considerable potential for reaching more eligible families.

3.12 There is a lack of evidence on interventions to reduce the risk of developing food allergies. The PDG noted that many pregnant women restrict the foods they eat due to a suspected food allergy. The DH/FSA recommends that women should seek advice from a health professional. The PDG agrees that individuals should not cut out food groups without advice from a dietitian, in case they omit important nutrient sources.

Supplements

3.13 The PDG welcomed the fact that Healthy Start provides free vitamin supplements (folic acid with vitamins C and D) specially formulated for pregnant women and free vitamin drops (vitamins A, C and D) for young children. Healthcare professionals need to be aware of both types of Healthy Start vitamin supplements. Maternal supplements are available free to all eligible women who are pregnant or have an infant under 1 year. Children's vitamin drops are available to all eligible infants and children under 4. The PDG noted that if the maternal vitamin supplements were also made available for women with a child between 1 and 4 years, the incidence of neural tube defects (NTDs) and prevalence of rickets could, potentially, be further reduced.

3.14 Maternal Healthy Start vitamin supplements are considerably cheaper than commercially available alternatives. The PDG noted that increasing the availability of these supplements from community pharmacies (and women's awareness of their affordability) would:

support recommendations on folic acid and vitamin D

reduce the risk of women taking multivitamin supplements containing vitamin A (which is not recommended during pregnancy).

3.15 Folic acid supplements reduce the risk to the fetus of NTDs such as anencephaly and spina bifida. The DH recommends that women who could become pregnant or who are already pregnant take them daily (400 micrograms [μg]) before conception and throughout the first 12 weeks of pregnancy. Higher doses (5 mg daily) are recommended for those who have had a previous NTD pregnancy or who have a family history of NTD. Higher doses are also recommended for women who have (or whose partner may have) an NTD and those who have diabetes (DH 2000).

Up to 50% of pregnancies are unplanned, so many women do not start taking folic acid supplements until they realise they are pregnant. Health professionals and others working with women of childbearing age need further training so that they can explain the importance of folic acid and folate. For example, they need to stress that eating folic acid and folate‑rich foods is important, but is not enough to reduce the risk of NTDs. Foods fortified with folic acid include: breakfast cereals and yeast extract. Those rich in folate include: peas, beans, lentils and orange juice.

A recent survey of the knowledge and attitudes of low‑income women to folic acid supplements showed that many did not understand either the serious nature of NTDs or the role of folic acid supplements in prevention(Food Standards Agency 2007). The authors emphasised the importance of explaining the reasons for recommending dietary and lifestyle change. In the case of folic acid, this includes an explanation of the nature, severity and lifelong consequences of having an NTD.

3.16 There have been many reports that rickets is re‑emerging in the UK though its prevalence in the population is unknown. Rickets is a clinical marker of poor pre‑ and postnatal bone health caused by vitamin D deficiency. The plasma concentration of 25 hydroxyvitamin D is widely used to indicate an individual's vitamin D status. A level below 25 nanomoles/litre (nmol/l) indicates risk of vitamin D deficiency. The 'National diet and nutrition survey of British adults' (Ruston et al. 2004) showed that about a quarter of British women aged 19–24 and a sixth of those aged 25–34 are at risk by this criterion.

Dietary sources of vitamin D are limited and the main source is skin synthesis on exposure of the skin to sunlight. However, at UK latitudes, there is limited sunlight of the appropriate wavelength, particularly during winter. Thus maternal skin exposure alone may not always be enough to achieve the optimal vitamin D status needed for pregnancy. During pregnancy, lack of vitamin D may adversely affect fetal bone mineralisation and accumulation of infant vitamin D stores for their early months of life.

Women and children of South Asian, African, Caribbean and Middle Eastern descent, and those who remain covered when outside, are at greatest risk. However, some white women living at the most southerly latitudes of the United Kingdom are also at risk. Javaid and colleagues (2006) found that the bone mineral mass of children aged 9 correlated significantly with their mothers' vitamin D status during pregnancy.

In 1991, COMA set a reference nutrient intake (RNI) of 10 µg of vitamin D per day for all pregnant and breastfeeding women. It also set an RNI of 7–8.5 µg daily for breastfed babies from 6 months, or earlier if there was increased risk of deficiency due to low maternal status. In most instances, these intakes cannot be met from diet alone: the average intake of women of childbearing age is 2.8 µg per day (Henderson et al. 2003). Thus an intake above RNI can only be guaranteed by taking a vitamin D supplement.

In 2007, the Scientific Advisory Committee on Nutrition (SACN) confirmed that these recommendations should remain unchanged. The DH and the Chief Medical Officer state that: all pregnant and breastfeeding women, breastfed babies from the age of 6 months (or earlier if the mother's vitamin D status in pregnancy was not adequate), formula‑fed babies receiving less than 500 ml formula a day and all children aged 1–4 years should receive vitamin D supplements (DH 2005).

The PDG was aware of widespread confusion among health professionals in relation to this policy and was concerned that the advice was not being followed. There is no evidence that vitamin D supplements at the doses recommended, in addition to what is normally consumed in the diet, are harmful. It was also noted that suitable supplements containing vitamin D are available free to mothers and to children eligible for Healthy Start benefits.

Infant feeding

3.17 Women from routine and manual groups are less likely to initiate breastfeeding and more likely to stop early. If exclusive breastfeeding for the first 6 months were actively protected, promoted and supported, the health inequalities experienced by mothers and children in low‑income families would be reduced (World Health Organization 2003).

3.18 Schemes to promote breastfeeding vary in their effectiveness and occasionally, where they have little effect, may not be good value for money. However, most established peer and professional educational breastfeeding interventions were estimated to be cost effective, even when the resulting health benefits were conservatively estimated. Indeed, if it is accepted that demonstrable health benefits in later life (for example, reduced risk of cardiovascular disease) are causally associated with breastfeeding, then virtually all breastfeeding schemes would be cost effective, and often extremely so.

3.19 Mothers who breastfeed need clear and consistent advice on how to maintain their milk supply and how to store expressed breast milk. The PDG hopes that the recommendations on storing expressed breast milk will encourage mothers to breastfeed for longer, especially those who return to work.

3.20 In the national 'Infant feeding survey 2005' (Bolling et al. 2007), almost half of mothers who had prepared powdered infant formula in the previous 7 days had not followed the key recommendations for its use. Parents need advice from independent, qualified professionals about the importance of following DH and FSA recommendations to reduce the risk of infection and over‑ or under‑concentrated feeds.

3.21 UK dietary recommendations for children aged 6–24 months are, for the most part, based on the 1994 COMA report 'Weaning and the weaning diet' and its subsequent updates (DH 1994a). This process involves a gradual transition from an exclusively milk‑based diet to one based, for the most part, on foods other than milk.

Health departments in England, Wales and Northern Ireland recommend that babies should be offered a gradually increasing amount and variety of solid foods, in addition to milk, from 6 months. This should include meat, fish, pulses, vegetables and fruit without added salt or sugar. Introducing solid foods too early or too late is undesirable. National infant feeding surveys have consistently shown that early introduction of solid foods is associated with lower socioeconomic position and educational attainment. The PDG welcomes recent evidence of a significant reduction in the proportion of infants weaned by 4 months: the proportion of mothers giving their babies solids before they are 3 months has more than halved since the revision of national policy (DH 2003). However, inequalities are still evident in this area.

Pre‑school children

3.22 The pre‑school years are an ideal time to establish the foundation for a healthy lifestyle. Parents are primarily responsible for their child's nutrition during these years, but child care providers also play an important role.

3.23 General dietary guidelines for adults do not apply to children under 2 years. Between 2 and 5 years the timing and extent of dietary change is flexible. By 5 years, children should be consuming a diet consistent with the general recommendations for adults (DH 1994b). It is recommended that the average salt intake for children should not exceed the following: 1 gram for infants aged 7–12 months; 2 g for children aged 1–3 years and 3 g for those aged 4–6 years. This can be achieved if children are given predominantly home‑cooked foods (SACN 2004b). The PDG welcomes the practical Caroline Walker Trust guidelines for food provision in childcare settings (such as day‑care centres, crèches, childminders and nursery schools) to encourage healthy eating from an early age (Crawley 2006). It also welcomes guidelines which address the specific eating and drinking issues facing children and adults with learning disabilities (Crawley 2007). These include issues related to breastfeeding, weight management, gastrointestinal disorders, swallowing difficulties and oral health.

3.24 Generally, children aged 1.5 to 6 years do not eat enough fruit and vegetables (particularly those from lower income and one parent families). However, they do eat a lot of added sugars (Gregory et al. 1995; Gregory et al. 2000). The PDG stressed that pre‑school children's diets are still an area of concern and should be addressed.

Weight monitoring

3.25 The way a baby's weight is measured and monitored varies considerably, in terms of the type of equipment used, the way data is documented and interpreted, and the way it is communicated to parents. Routine and frequent monitoring of the weight of newborn babies (in their first 2 weeks of life) is important as part of an overall assessment of their needs. However, ongoing weekly weighing is unnecessary for healthy babies who give no cause for concern. The PDG is concerned that existing guidance from the Coventry consensus (Hall 2000) is not widely implemented. This states that unnecessary weighing of older babies may lead to an inappropriate intervention and undermine parents' confidence.

3.26 Weight monitoring alone, as currently practised, does not provide information to justify changes in infant feeding practices. Parents may need advice about infant feeding from a multidisciplinary team. Effective advice and support will take the parents' views into account.

Training

3.27 The PDG noted that some dietary advice given by those responsible for the care of mothers and pre‑school children is not evidence‑based and that information provided by health professionals is not always consistent. Confusion about national nutrition policy relating to mothers, infants and children needs to be addressed. In addition, women who are preparing for pregnancy need help to understand the long‑term consequences on their child's health of poor nutrition during pregnancy. Professionals need training in both these areas so they can offer informed and practical advice on food (not just nutrients). They should also participate in continuing professional development programmes to keep their knowledge up‑to‑date.

3.28 Many of the recommendations have training implications for health professionals. Those offering training in nutrition need to have an appropriate qualification (for example, as a dietitian or a registered public health nutritionist). They must also recognise the importance of communication and inter‑personal skills.

3.29 Cultural beliefs may prevent people from accepting professional advice. In addition, mothers may be subjected to conflicting and inconsistent advice from health professionals, literature, media sources and product labelling.